Integrative Approaches to Pharmacotherapy—A Look at Complex Cases Chapter 60: Integrative Approaches to Pharmacotherapy—A Look at Complex Cases

Managing Multiple Problems in a Single Patient The practitioner must evaluate possible medication therapies and select the best patient-specific option. This level of complexity is reflective of real-life situations and requires a systematic approach to the patient to manage the complexities.

Issues Affecting Medical Conditions Economic Social Emotional Cultural

Issues Related to Medication Therapy Cost of medications Selection of treatment options Emotional reminder of illness association with chronic medication-taking behavior Culturally accepted treatment options

Problem-Oriented Medical Record (POMR) Each of the patient’s medical problems is identified and prioritized in order of importance. The order of the problems depends on the acuity and severity of the situation. Typically, the most severe and acute problems are listed first, followed by the chronic conditions, and then problems requiring preventive measures (e.g., smoking cessation). SOAP note technique is used.

SOAP Note Technique (S)ubjective (O)bjective (A)ssessment (P)lan

Subjective versus Objective Data The subjective and objective components are the data that support the identification of the prioritized problem. Subjective data: refer to information provided by the patient (or other individual) that cannot be independently verified. Objective data: often are laboratory data or health assessments (e.g., blood pressures) performed or observed by the practitioner.

Question A practitioner is examining a patient who grimaces when his leg is moved. What type of data is the patient displaying? Objective Subjective Objective and subjective This does not qualify as data

Answer A. Objective Rationale: The objective data often are laboratory data or health assessments (e.g., blood pressures) performed or observed by the practitioner. The grimace denotes pain upon movement of the limb. The subjective data refer to information provided by the patient (or other individual) that cannot be independently verified, for example, if the patient stated that he had pain but was not physically displaying signs of pain.

Information Contained in SOAP Note Assessment Chief complaint History of the present illness Past medical history Family and social history Medication history Results of review of systems Physical examination and laboratory results

SOAP Note—Therapeutic Plan Additional diagnostic tests necessary to confirm or rule out the suspected diagnosis Referral to other practitioners as necessary Information about changes in therapeutic plans Adding or discontinuing drug therapy Identifying therapeutic goals Establishing monitoring parameters

Question In which section of the SOAP note does the practitioner delineate the potential diagnosis related to the problem? Subjective data Objective data Assessment Plan

Answer C. Assessment Rationale: The assessment section of the SOAP note integrates the subjective and objective information and is where the practitioner delineates the potential diagnosis related to the problem. The last portion of the note is the therapeutic plan. In this section, the practitioner may include additional diagnostic tests necessary to confirm or rule out the suspected diagnosis.

Anticipating Problems Patient noncompliance Adverse reactions Interacting drugs

Other Information Needed Before Prescribing Assessment of specific information related to drug therapy Inventory of patient-reported allergies including an assessment of drug allergies Prescription medication use Nonprescription medication use and complementary and alternative product use

Case Study Parameters Specific goals for treatment Specific goals of therapy Type of drug therapy chosen Parameters for monitoring success of the therapy Specific patient education based on the prescribed therapy Adverse reactions for selected agent that would cause a change in therapy

Case Study Parameters (cont.) Second-line therapy Appropriate over-the-counter and/or alternative medications Recommended lifestyle changes Drug–drug or drug–food interactions related to chosen agent

Summary When managing multiple problems in a single patient, the practitioner must evaluate possible medication therapies and select the best patient-specific option. This level of complexity is reflective of real-life situations and requires a systematic approach to the patient to manage the complexities. One of the more common methods for organizing medical information is the problem-oriented medical record (POMR), which uses the SOAP note for organizing patient information.